CDC/IDSA COVID-19 Clinician Call - June 5, 2021
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CDC/IDSA
COVID-19
Clinician Call
• 68th in a series of weekly calls, initiated by CDC as a
forum for information sharing among frontline
clinicians caring for patients with COVID-19
June 5, 2021
• The views and opinions expressed here are those
of the presenters and do not necessarily reflect the
Welcome & Introduction official policy or position of the CDC or
Susanna Visser, DrPH, MS IDSA. Involvement of CDC and IDSA should not be
Senior Advisor, Policy and Partnerships Team viewed as endorsement of any entity or individual
HSWS Task Force COVID-19 Response involved.
Associate Director for Policy & Extramural Program
Division of Vector-Borne Diseases • This webinar is being recorded and can be found
National Center for Emerging and Zoonotic Infectious online at www.idsociety.org/cliniciancalls.
Diseases
Centers for Disease Control and Prevention
1
Debbie Dowell, MD, MPH, CAPT, USPHS
Deputy Chief Medical Officer
COVID-19 Response
Centers for Disease Control and Prevention
Emilia (Emily) Koumans, MD, MPH
Clinical Disease and Health Systems Team Lead
COVID-19 Response
Centers for Disease Control and Prevention
TODAY’S TOPIC: Lilian Abbo, MD, FIDSA
Chief Infection Prevention and Antimicrobial Stewardship
Update on Breakthrough Jackson Health System
Professor of Infectious Diseases
University of Miami Miller School of Medicine
Infections
Shweta Anjan, MD
Assistant Professor of Clinical Medicine
Division of Infectious Diseases
University of Miami Miller School of Medicine
David Andrews, MD
Associate Professor of Clinical Pathology
University of Miami Miller School of Medicine
CLIA Laboratory Director, Jackson Memorial Hospital
2
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3
CDC Science Brief: COVID-19 Vaccines and Vaccination
Debbie Dowell, MD, MPH
Deputy Chief Medical Officer, COVID-19 Response
CDC/Infectious Diseases Society of America
Clinician Call
June 5, 2021
cdc.gov/coronavirus
CDC Science Brief: COVID-19 Vaccines and Vaccination
▪ Available at www.cdc.gov/coronavirus/2019-ncov/science/science-
briefs/fully-vaccinated-people.html
▪ Purpose: to summarize the evidence supporting CDC’s Interim Public
Health Recommendations for Fully Vaccinated People
▪ Last updated April 2, 2021
– Guidance update released April 27
– Guidance update released May 13
– Substantial increase in the evidence base
Summary of Major Updates to Science Brief
▪ 17 new studies showing effectiveness of COVID-19 vaccination
– First real-world study of Johnson & Johnson’s Janssen vaccine
▪ 9 new studies supporting reductions in transmission of SARS-CoV-2 by
vaccinated people who become infected
– 3 new studies of vaccine effectiveness against asymptomatic infection
– 4 new studies showing reduced viral load among infected vaccinated people
– 2 new studies directly documenting reduced transmission
▪ More data on effectiveness of mRNA vaccines against variants of concern
▪ Streamlined content to focus on robust body of vaccine evidence
– Created separate brief for evidence supporting travel recommendations
Summary of Current Evidence (1st of 2 summary slides)
▪ Effectiveness of COVID-19 vaccines ≥7 days post-vaccination
– mRNA vaccines 85%-99% effective against symptomatic disease
• One study from Denmark estimating 64% effectiveness in long-
term care residents
– mRNA vaccines 92%-98% effective against severe disease and 87%-
97% against hospitalization
– J&J/Janssen vaccine 77% effective against symptomatic disease
Summary of Current Evidence (2nd of 2 summary slides)
▪ Effectiveness of COVID-19 vaccines against transmission
– mRNA vaccines 65%-92% effective against asymptomatic infection
– Transmission risk to household contacts approximately halved by
vaccination
▪ Effectiveness of COVID-19 vaccines against variants
– mRNA vaccines: >85% overall when B.1.1.7 prevalent
– Pfizer-BioNTech: 90% against B.1.1.7; 75% against B.1.351
– J&J/Janssen: reduced VE when B.1.351 prevalent but ≥73% vs. severe
disease
What We’re Still Learning
▪ Effectiveness of vaccination among immunosuppressed populations
– Reduced immunogenicity of vaccination observed among several groups
▪ Duration of immunity
▪ Level of population immunity needed for community protection
▪ Real-world effectiveness of Johnson & Johnson’s Janssen vaccine on outcomes
including severe disease, hospitalization and death.
▪ More about effectiveness against viral transmission and infection with variants
of concern
Key Points ▪ All COVID-19 vaccines currently authorized in the United States are effective against COVID-19, including serious outcomes like severe disease, hospitalization, and death. ▪ A growing body of evidence indicates that people fully vaccinated with an mRNA vaccine are less likely to have asymptomatic infection or to transmit SARS-CoV-2 to others. Studies are underway to learn more about the benefits of Johnson & Johnson/Janssen vaccine. ▪ Available evidence suggests the currently authorized mRNA COVID-19 vaccines provide protection against a variety of strains, including B.1.1.7 and B.1.351; other vaccines show reduced efficacy against B.1.351 but may still protect against severe disease.
For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
The Miami Experience at Jackson Health System
Variants, Vaccinations and COVID-19
Breakthrough Infections
Lilian Abbo, M.D., FIDSA
Chief Infection Prevention & Antimicrobial Stewardship
Jackson Health System
Professor of Infectious Diseases
University of Miami Miller School of MedicineDisclosure • No conflicts of interest to disclose
JMH licensed
1550 beds
270 ICU beds
2 Community Hospitals
2 Long Term Care
Facilities 12,000 employees
500 University of Miami Faculty
4 Miami-Dade
Corrections/ JailsWhat about our Healthcare workers?
As of June 3, 2021
7401 vaccinated
19 vaccine
breakthrough
cases identified
(rate 0.25%)Case Presentation
• 61-year-old male
• Past Medical history: HTN, Nephrotic Syndrome, ESRD on hemodialysis since 6/2020
• Received 2 doses of mRNA vaccine (Pfizer-BioNTech) 78 days prior
• Presented with fever, cough, dyspnea, nausea, and diarrhea for 3 days
• No prior COVID-19 infection and no severe reactions to the vaccine
• On physical exam: patient was in distress, with decreased breath sounds bilaterally
16Labs and Imaging
WBC 19.9
10(3)/mcL D-dimer: 1.57 CRP: 8.2
ANC: 17.8 Platelets: 235
mcg/ml mg/dl
ALC: 1.2
Blood
Ferritin: 2094 LDH: 1042 Troponin:
Cultures:
ng/ml unit/L 0.027 ng/ml
NegativeHospital Course
Day of
Hospital
admission: COVID-19
78 days Antibodies
from second Detected
dose,
Total: 156 Day 6 – 8,
On 4 L/min
of O2 IgG: 22.18 4-5 L via NC
Day 2: Increased O2 Day 3-5, Discharged
requirements; HFNC Home
45/FiO2 100% 15L NRB
Remdesivir and
dexamethasoneAcknowledgments
• ID Colleagues
Drs Laura Beauchamps, Jovanna Bertran, Foluaskin Ayoade, Stephen Morris, Yoichiro Natori, Jacques Simkins, Shweta Anjan
• University or Miami Pathology/Genetics/Cancer Center Colleagues
Drs. Merce Jorda (Chair), Emmanuel Thomas, Sion Williams (Cancer Center), Yi Zhou, Anthony Griswold (Genetics), Jacob McCauley
(Genetics), Octavio Martinez, Ranjini Valiathan, Ms. Yamina Caratini
• JHS Antimicrobial Stewardship and Pharmacy Teams
Venessa Goodnow, Ennie Cano, Ana Vega, Kailyn Deronde, Meshell Maxam, Christine Vu, Julio Simon, Renata Boatright, Veronica Salazar.
• JHS Infection Prevention Team
Kathleen Sposato, Maribel Ruiz, Adriana Jimenez, Javier Cardozo, Regina McDade, Natalia Fadul, Jolie Dobson, Paula Weisberg, Regina
Williams, Kelley Manzanillo, Christopher Christy, Delia Roberts, Olga Orozco, Doreen Amarsingh
• JHS Microbiology Lab Team
• Huy Dingh, Biaggio di Pascale, Clara Prado, Sallie Wright, Katiuska Parra, Joanna Danton
• JHS Information and Technology
• Dr. Alina Brebene, Dr. Joseph Zeitouini, Jermaine Allen, Donna BenjaminThank you @liliabbo
Updates on COVID-19 Vaccine
breakthrough infections: Clinical
perspective from Miami
Shweta Anjan, MD
Assistant Professor of Clinical Medicine
Division of Infectious Diseases
University of Miami Miller School of MedicineDisclosure • No conflicts of interest to disclose
Vaccine breakthrough
infections
Immunocompetent Immunocompromised
N=9 N=18Immunocompetent
Demographics Co-morbidities
• Mean Age: 70 years (58 - 89) • 67% HTN
• 67% Male • 89% BMI >25
• 78% Hispanic • 22% DM
Median time from vaccine to COVID diagnosis: 67 days (9-115) (56% mRNA, 44% Ad26.COV2.S)
All required hospital admission (67% ICU, 33% COVID-19 Ward)
Management
Outcomes
• Remdesivir + dexamethasone 55%
• 89% recovered and discharged home
• Convalescent plasma, tocilizumab 11%
• 11% (n=1) mortality
• Supportive care 11%Immunocompromised: Solid organ transplant recipients
• Antibody response lower than general population
• Severe immunosuppression has been linked to Chronic COVID-19 and
Virus variants
1. Boyarsky BJ et al. Antibody Response to 2-Dose SARS-CoV-2 mRNA Vaccine Series
in Solid Organ Transplant Recipients. JAMA. 2021;325(21):2204–2206.
2. 2. Abbasi J. Researchers Tie Severe Immunosuppression to Chronic COVID-19 and
Virus Variants. JAMA. 2021;325(20):2033–2035.Immunocompromised: Solid organ transplant recipients
• As of April 30, 2021, 2957 SOTR have been vaccinated →18 cases (breakthrough rate
0.60%)
• 83% were fully vaccinated
• Demographics
• 58 (41 – 81) years
• 50% Female
• 72% Hispanic ethnicity
• 50% →exposed to an unvaccinated family member with COVID-19TYPE OF ORGAN TRANSPLANT
Kidney Liver Lung Combined
• Time from transplant to first dose of the vaccine
17% →26 (range 2 - 90) months
– 3/18 within 6 months of transplant
5%
• Time from vaccine to diagnosis →25 days (range, 4
11%
– 96)
67%Clinical Course
Hospital admission Outpatient
56% 44%
Remdesivir 100%
Casirivimab/Imdevimab
High dose steroids 90% 39%
Total plasma exchange 30%
28% admitted within 28 days of receiving MAB
Recovered and Death Still hospitalized for non-COVID-19 care
discharged
10% (n=1) 10%
home
All Recovered
80%In Summary • Severe COVID-19 and mortality can occur in vaccine breakthrough cases • Encourage patients to seek medical care early while they may qualify for MAB • Immunocompromised individuals should continue wearing a mask • Vaccine breakthrough data comparing available vaccines (mRNA, viral vector and adjuvanted protein platforms) are needed • Vaccine protocols may need to be tailored by State, population and predominant variant
Questions? sxa835@med.miami.edu @shwetanjan
SARS-CoV-2 gene variant trends from
patient and student samples
in Miami-Dade County, Florida
David Andrews, MD
Associate Professor of Clinical Pathology
University of Miami Miller School of Medicine
Vice-chief, Pathology, Jackson Health System Hospitals
CLIA Lab Director, Jackson Memorial, Jackson North, Jackson South Hospitals
June 5, 2021Disclosure • No conflicts of interest to disclose
Study Design
Non-HSRO/deidentified samples for Surveillance effort
• Beginning mid-January 2021, residual clinical samples were retrieved
from the lab after Positive SARS-CoV-2 molecular results obtained.
• Samples initially screened in Pathology by qPCR with the TaqPath
(TaqPath COVID-19 PCR, Thermo Fisher Scientific) assay to detect the
B.1.1.7 UK Variant as manifested by the S-Gene target failure (SGTF)
• Sequencing methods developed in our Cancer Center (Sylvester
Comprehensive Cancer Center) Oncogenomics Core facility, where the
NEB Biolabs ARTIC method of multiplexed amplicon-based whole viral
genome sequencing was implemented on the Illumina NovaSeq
platform. Program overseen by Dr. Sion Williams.
• Bioinformatics pipeline was handled by Dr. Anthony Griswold in our
UM Genetics Institute (Hussman Institute for Human Genomics)Sample sources – weekly collections
Jackson Memorial Hospital
Jackson North Medical Center
Jackson South Medical Center
Ambulatory Urgent Care Centers
UHealth Tower
(University of Miami Hospital)
Sylvester Cancer Center Undergraduate Students
Active SARS-CoV-2
screening programOverall lineage trends: Varied & Diverse, like Miami!
PANGO LineagesB.1.1.7 trending down
Increasing prevalence Jan -> May 2021
Variants of Concern, Variants of Interest, emerging Variants of interest.
B.1.427/29 “CA” VOC
B.1.526 “NY” VOI
VOC, VOI,
emerging VOI,
other than B.1.1.7
P.1 “Brazil (Manaus)” VOC
B.1.1.7 “UK” VOC
March 2021 (N = 138) April 2021 (N = 162) May 2021 (N = 146)
Feb* 2021 (N = 105)
*includes late Jan samples
PANGO LINEAGEMay 2021 NGS (SARS-Cov-2)
May 2021 NGS summary:
Approximately
88% of samples
sequenced revealed
a PANGO lineage
associated with a
VOC, VOI, or
an emerging variant
of interest.Feb –> early May VOC/VOI expansion
Conclusion: Despite significant expansion
of VOC/VOI, case numbers are falling in association
with increased vaccination rate. The data
suggests vaccines provide good protection.
Percent vaccinated
Miami-Dade County
graphs retrieved 6-4-2021 from
covidactnow.org
(source data from Florida Dept. of Health)Quote:
Vaccine evaluations against new variants will be more challenging going forward as data from randomized,
placebo-controlled clinical trials become less common owing to enhanced availability of vaccines.
A global scientific agenda that encompasses extensive genomic surveillance, detailed “correlate of protection”
evaluations, and robust post-introduction surveillance and sequencing is necessary to measure the effect of
new and current vaccines against SARS-CoV-2 variants.
NEJM 384;20 May 20, 2021Thank you!
dandrews@miami.edu
Acknowledgments:
UM: Dr. Merce Jorda (Pathology chair) and Dr. Stephen Nimer (Cancer Center director)
JHS: Dr. Peter Paige, CMOQ&A and Discussion
43Links and Resources
▪ Slide 5 - CDC Science Brief: COVID-19 Vaccines and Vaccinationwww.cdc.gov/coronavirus/2019-ncov/science/science-briefs/fully-
vaccinated-people.html
▪ Slide 37 – Calculator https://www.medcalc.org/calc/comparison_of_proportions.php
4445
Specialty Society Collaborators
An online community bringing together information and opportunities
for discussion on latest research, guidelines, tools and resources from a American Academy of Family Physicians
variety of medical subspecialties around the world. American Academy of Pediatrics
American College of Emergency Physicians
American College of Physicians
American Geriatrics Society
American Thoracic Society
Pediatric Infectious Diseases Society
Society for Critical Care Medicine
Society for Healthcare Epidemiology of America
Society of Hospital Medicine
Society of Infectious Diseases Pharmacists
www.COVID19LearningNetwork.org
@RealTimeCOVID19
#RealTimeCOVID19CDC-IDSA Partnership: Clinical Management Call Support
FOR WHOM?
- Clinicians who have questions about the clinical
management of COVID-19
WHAT?
- Calls from clinicians will be triaged by CDC to a group of
IDSA volunteer clinicians for peer-to-peer support
HOW?
- Clinicians may call the main CDC information line at 800-
CDC-INFO (800-232-4636)
- To submit your question in writing, go to
www.cdc.gov/cdc-info and click on Contact Form
cdc.gov/coronavirusidweek.org
Virtual Conference
Save the Date
Sept. 29 – Oct. 3, 2021
Important Dates:
• Registration is Open
Attend, Learn & Collaborate. • Abstract Submission Deadline – June 9
Advancing Science, Improving Care • Case Submission Deadline – June 9We want to hear from you!
Please complete the post-call survey.
Starting in June the calls will be held the
Continue the twice a month:
conversation on Twitter Next Call
Saturday, June 19
@RealTimeCOVID19 Topic: Myocarditis
#RealTimeCOVID19 A recording of this call will be posted at
www.idsociety.org/cliniciancalls
-- library of all past calls available --
Contact Us:
Dana Wollins (dwollins@idsociety.org)
Deirdre Lewis (dlewis@idsociety.org)
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